Medical Claim Analyst

This is a fully remote position, open to applicants in Texas.

📋 Description

• Perform post-service claim evaluations to assess whether providers and members can receive reimbursements for services rendered.

• Initiate the CCR process following a thorough review of claims and their histories.

• Gather system data, claim histories, plan details, and further research into necessary templates.

• Collaborate with clinicians and Medical Directors as necessary.

• Evaluate provider and member claims against the CCR review criteria.

• Adhere to workflows, templates, legal standards, and compliance mandates.

• Organize and prioritize tasks to meet regulatory and CCR claim processing deadlines.

• Assess coverage, verify eligibility and benefits, identify inconsistencies, and apply Medical Claim Management policies and procedures.

• Coordinate with internal and external teams and personnel to review claims and resolve issues.

• Utilize various systems, including EWM, ASD, ATV, MedCompass, and HRP.

• Maintain and utilize resource materials and systems to effectively manage job responsibilities.

• Safeguard member confidentiality in accordance with company policies.

⛳️ Requirements

• Minimum of 2 years of relevant experience.

• Proven capability to manage multiple tasks competently, accurately, and efficiently.

• Preferred knowledge of utilization management regulations and claim processing guidelines.

• Previous experience in claims processing or customer service is preferred.

• Must possess a verifiable High School Diploma or GED.

• Proficient in working with multiple systems, including EWM, ASD, ATV, MedCompass, and HRP.

• Commitment to adhering to legal, regulatory, compliance, and confidentiality standards.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.

• Comprehensive medical coverage.

• Dental insurance.

• Vision insurance.

• Paid time off.

• Retirement savings options.

• Access to wellness programs.

• Additional resources supporting physical, emotional, and financial health, based on eligibility.